Rebound Catatonia Associated With Injectable Paliperidone.

Paliperidone is an atypical antipsychotic medication commonly used to treat schizophrenia, schizoaffective disorder, and bipolar disorder. It is a metabolite of risperidone and has a similar mechanism of action, primarily blocking dopamine 2 receptors (D2 receptors) in the brain. Paliperidone has various adverse effects, including extrapyramidal symptoms, weight gain, and metabolic disturbances. Catatonia is rare but severe side effects can occur in the context of an underlying psychiatric, neurologic, or general medical condition. Paradoxically, antipsychotics for treating schizophrenia or bipolar spectrum disorders can precipitate or worsen catatonic symptoms. The report suggests that 17-19% of all cases diagnosed as catatonia due to other medical conditions are medication-induced. Catatonia is a neuropsychiatric syndrome that presents as a cluster of psychomotor signs and symptoms resulting in movement and behavior aberrations. Various symptoms, including mutism, stupor, rigidity, and abnormal movements, characterize catatonia. Catatonia is a potentially life-threatening condition requiring prompt recognition and management. Here, we present a case of a patient with catatonia associated with long-acting injectable paliperidone intramuscular therapy in a patient with schizophrenia.

Pseudobulbar Affect Presenting as Aggressive Behavior.

Pseudobulbar affect (PBA) is an affective disorder of emotional expression characterized by frequent uncontrollable outbursts of laughing or crying. It is usually associated with stroke, traumatic brain injury, and other neurological conditions. This disorder can present a challenge to clinicians to distinguish this from mood disorders or to diagnose this disorder in the context of underlying mood disorders. In addition, the delay in the diagnosis can impact patients' quality of life. We describe a 48-year-old man who presented with frequent episodes of sudden, frequent, uncontrollable laughing two years after his recurrent stroke. The patient initially had his first stroke about three years ago and had a recurrent stroke eight months after his first stroke. A few days after getting discharged after his second stroke, the patient was admitted to the psychiatric unit after his family members reported aggressive behavior. The patient also reported symptoms of depression and was discharged on escitalopram for mood and divalproex for his aggressive behavior. Unfortunately, the patient was not compliant with these medications with no resolution of his symptoms. The patient was then treated with dextromethorphan-quinidine, escitalopram, and divalproex, resulting in significant improvement in his mood and aggressive behavior with a resolution of uncontrollable laughing spells.  Clinicians are encouraged to inquire about symptoms of pseudobulbar affect in the context of stroke or other neurological disorders. Appropriate management of this condition can help improve patients' symptoms and positively affect their wellbeing.

Sleepwalking, sleep-related eating disorder and sleep-related smoking successfully treated with topiramate: a case report.

We describe a 45-year-old married woman with sleepwalking, sleep-related eating disorder, and sleep-related smoking behavior, but without restless legs syndrome. The patient had a history of mild obstructive sleep apnea with an AHI of 12.6/hour with an oxygen saturation nadir of 95%, which resolved after bariatric surgery. Treatment with topiramate 100mg at bedtime controlled all three parasomnias for ten months at the latest follow-up, with relapse occurring whenever topiramate was stopped. To our knowledge, this is the first reported successful treatment of sleep-related smoking. Clinicians are encouraged to inquire about other types of parasomnias, and other sleep disorders such as narcolepsy, in patients presenting with a complaint of one parasomnia.

N-acetylcysteine in the Treatment of Internet Gaming Disorder.

Internet gaming disorder (IGD) is the persistent and recurrent use of the internet to engage in video gaming through a single or multiplayer interface that can lead to significant impairment or distress. With technological advancements in the last decade via portable handheld devices, along with their global availability, video games have found a new medium in which they can provide instantaneous access for casual and enthusiastic users alike. Unfortunately, this exponentially increases the possibility of addiction. IGD shares a similar pathophysiological etiology to addiction as drugs or gambling. However, it can be challenging to manage IGD due to the ease of video game access and limited understanding of the newly recognized disorder. This study aims to fill in the knowledge gap concerning the limited research on internet gaming addiction, its consequential effects on human cognitive-behavioral functioning, and pharmacotherapy management as observed in our patient, who developed IGD, starting initially as a casual recreational hobby among peers. This case also highlights the lack of social awareness and seriousness attributed to this disorder. It focuses on using N-acetylcysteine in the management as well as other psychological and psychotropic drugs.

Acute Psychosis Following Corticosteroid Administration.

Glucocorticoids are commonly used to treat endocrine as well as non-endocrine disorders. Unfortunately, these agents are associated with multiple adverse effects affecting various organ systems. A 55-year-old woman with type 2 diabetes mellitus and hypertension with no past psychiatric history was admitted to the hospital for acute hypoxic respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. The patient did not exhibit any psychiatric symptoms during the initial admission. However, she was re-admitted three days after the initial discharge, presenting with acute psychosis following the intravenous dexamethasone administration for seven days. Neuropsychiatric effects of glucocorticoids include depression, mania, agitation, mood lability, anxiety, insomnia, catatonia, depersonalization, delirium, dementia, and psychosis. Clinicians should be aware of the acute neuropsychiatric side effects of corticosteroids and evaluate patients for delirium if clinically indicated. Further research is needed to identify the pathophysiology and predisposing factors contributing to neuropsychiatric side effects of corticosteroid administration. The use of atypical antipsychotics in the management of these sequelae needs to be explored as well.

Herbal Supplements: Can They Cause Hypomania?

Herbal medication use is prevalent and increasing in the general population. A comprehensive review of complementary and alternative medicine use including herbal medications and supplements is often overlooked by physicians. Patients generally believe that all herbal products are safe without any side-effects. Herbal medications may have complex pharmacodynamics and can be associated with various psychiatric symptoms. The general population, as well as physicians, may be unaware of the risks and side-effects associated with herbal supplement use and further research may be needed. The objective is to describe a case report of acute onset of symptoms of hypomania associated with the increasing use of herbal supplements. A 49-year-old man developed symptoms of hypomania after a two-month history of daily use of a combination of more than 25 herbal supplements and daily cannabis use. Hypomania symptoms were temporally associated with the use of multiple herbal supplements that included ginseng. We recommend that a thorough history of medication use including herbal supplements and other alternative medications and a collateral report from family members and other providers including herbalists be obtained on all patients presenting with psychiatric symptoms. Further research is needed to identify the pharmacodynamics, risks, and adverse effects, and drug and food interactions of each herb.

Acute Psychosis and COVID-19 Infection: Psychiatric Symptoms in Hospitalized Patients.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has resulted in various medical and psychosocial consequences globally. Respiratory infections are common among patients infected with the SARS-CoV-2 virus, the causative virus of coronavirus disease 2019 (COVID-19). However, various psychiatric and neurocognitive symptoms and sequelae of COVID-19 have been reported as well.  This study aimed to describe two clinical case reports of patients with no prior history of psychiatric illnesses admitted to the psychiatric inpatient unit with acute onset of psychosis. A 49-year-old woman with no past medical history and no past psychiatric history was admitted to the inpatient psychiatric unit with suicidal ideation and was noted to have acute psychosis. A 56-year-old woman with a history of hypertension with no past psychiatric history was admitted to the hospital with acute hypoxic respiratory failure secondary to COVID-19 pneumonia and was noted to have acute psychosis.  Various psychiatric and neurocognitive symptoms and sequelae of COVID-19 have been reported. However, the pathophysiology, direct biological effects of the disease, treatment modalities, worsening of symptoms due to various medications, and other long-term sequelae are not fully understood. Therefore, clinicians should be mindful of neuropsychiatric symptoms and conduct a detailed history and physical examination on all patients presenting with psychiatric symptoms in the context of COVID-19. It is also essential to assess for signs and symptoms of delirium in patients presenting with neuropsychiatric symptoms. Further research is needed to identify the etiology, predisposing factors, exacerbating or precipitating factors contributing to neuropsychiatric symptoms associated with infection with the SARS-CoV-2 virus. In addition, the pathophysiology contributing to these symptoms and pharmacological interventions for managing these sequelae need to be evaluated.